In the light of previously described post-radiotherapy RUF size with a mean of 2.8cm
 and average diameter of 3.2cm
, the RUF presented in our paper should be described as moderate sized. It is said that patients with a fistula that is greater than 1cm in diameter should undergo gracilis interposition in conjunction with primary rectal repair and buccal mucosa grafting urethral reconstruction
. However, the issue of RUF classification and patients' stratification remains open in this clinical setting.
The fistula described is a late sequela of BT. Severe perineal pain, mild bleeding, and local proctitis were predisposing factors. These RUF predictors should be taken into consideration responsibly because a long-term patient's surveillance plan can be established for timely diagnosis of RUF because it can occur a few years after Iodine-125 seed implantation
. Furthermore, because an anterior rectal biopsy after prostate radiation has been associated with a higher incidence of RUF formation, an anterior rectal biopsy should not be performed unless there is an obvious cancer staging-related indication for a biopsy. RUF formation after BT is reported to be up to 8.8% if an anterior rectal biopsy is taken after this radiotherapy procedure
Long-term local use of cortisone for a conservative treatment of proctitis which is associated with BT is controversial. There are no reports supporting such conservative management of post-BT proctitis. Retrospectively, we assume that long-term steroid therapy for proctitis was a risk factor for RUF. We also postulated that HBOT may result in accelerated healing of injured tissues because it is thought that HBOT improves oxygen supply to wounds and therefore improves their healing. Again, there is no evidence supporting the HBOT in the management of patients with radiation-induced pelvic soft tissue necrosis including proctitis
As there is no standardized treatment for a BT-induced RUF the responsibility for treatment is borne by the physicians in charge. Our chosen surgical strategy resulted in a good outcome and it was similar to an earlier proposed procedure
. Nevertheless, the case report highlights one significant difference: there was no attempt to perform substitution urethroplasty either way, by primary repair or buccal mucosa reconstruction
. Moreover, postoperative formation of a membranous urethral stricture up to 1.5cm was predicted before and during the reconstructive surgery. Optic internal urethrotomy was a further treatment option because the urethral stricture was 1.5cm in length. Timely gracilis muscle transposition and rectal repair were key elements of successful RUF treatment. Although it is believed that radiotherapy-induced RUFs are much more challenging to reconstruct than inflammatory, iatrogenic, and traumatic RUFs because the magnitude of fibrotic tissue in the area of RUF is extensive
, it is not the case for every patient. Duration from insertion of radioactive implants to reconstructive surgery is possibly the main factor for the magnitude of fibrotic tissue around the RUF. Finally, in terms of good quality of life, it is believed that transperineal repair with gracilis muscle interposition is an effective treatment for patients with complex RUFs following radiotherapy. However, long-term follow-up studies are needed.